This webinar is presented by Tonights panel Dr Konrad Kangru Prof - - PDF document

1

Supported by The Royal Australian College of General Practitioners, the Australian Psychological Society, the Australian College of Mental Health Nurses and The Royal Australian and New Zealand College of Psychiatrists

DATE:

November 12, 2008 Webinar Tuesday, 23rd February 2016

Working Together to Recognise and Treat Complicated Grief

This webinar is presented by

Tonight’s panel Facilitator

Dr Konrad Kangru GP (Qld) Mr Greg Roberts Social Worker / Bereavement Counsellor (Vic) A/Prof Moira O’Connor Psychology Academic (WA) Ms Vicki Cowling Social Worker and Psychologist (Vic) Prof Kay Wilhelm Psychiatrist (NSW)

2

Ground Rules

To help ensure everyone has the opportunity to gain the most from the live webinar, we ask that all participants consider the following ground rules:

• Be respectful of other participants and panellists. Behave as if this were a

face-to-face activity.

• Post your comments and questions for panellists in the ‘general chat’ box.

For help with technical issues, post in the ‘technical help’ chat box. Be mindful that comments posted in the chat boxes can be seen by all participants and

• panellists. Please keep all comments on topic.
• If you would like to hide the chat, click the small down-arrow at the top of the

chat box.

• Your feedback is important. Please complete the short exit survey which will

appear as a pop up when you exit the webinar.

Learning Outcomes

Through an exploration of grief and depression, the webinar will provide participants with the opportunity to:

• Describe the difference between complicated grief and depression
• Implement key principles of providing an integrated approach in the early

identification of complicated grief

• Identify challenges, tips and strategies in providing a collaborative response

to assisting people experiencing complicated grief after a significant loss.

3

General Practitioner Perspective

GP Context

• Usual carer for Dorothy over several years

– Probably was also Arthur’s GP – Watch out for guilt, transference and counter-transference

• Has watched her progress over that time

– Initial grief response but Rheumatoid Arthritis since

• Knows Dorothy very well

– Often difficult to notice subtle changes over time

• May not be suspecting Major Depressive Disorder

– Revelation that Dorothy “just doesn’t want to be here anymore” a major alarm

• Will remain central to ongoing care co-ordination

Dr Konrad Kangru

General Practitioner Perspective

Practicalities of Care for GP

• Dorothy is eligible for GP Mental Health Care Plan (1)

– (MBS Items 2700,2701,2715,2717)

• Simple grief should not be a disorder
• Adjustment Disorder (F43.2) and Recurrent Depressive Disorder

(F33) both valid ICD-10 diagnoses (2)

– K10, DASS both entirely appropriate initial assessment tools

• Suicidality must be assessed

– Intent, access to means, previous attempts, supports – May need Involuntary Mental Health Assessment

Dr Konrad Kangru 1. http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A45&qt=noteID&criteria=2715 2. http://apps.who.int/classifications/icd10/browse/2016/en#/F30-F39

4

General Practitioner Perspective

What to do?

• Pharmacotherapy?

– Very cautious about sedatives or anxiolytics – SSRI might have a role but needs time

• Psychologist referral?

– Completely appropriate but not for acute care – May be able to access online resources in interim

• Psychiatrist input?

– Definitely indicated when concerned about suicide – Inpatient or Outpatient, Voluntary or Involuntary

Dr Konrad Kangru

Psychiatrist Perspective

What would be issues for me?

• What was her personality style, general and under stress?
• What was her marriage like over time? Before Hb’s death? Any

marital problems (i.e. other reasons for prolonged grief)?

• What about previous health? Has she definitely got RA? Is it well

controlled? On prednisone? Other autoimmune conditions?

• Any Hx depression or bipolar disorder in her/family?
• What has she been doing (social interaction/exercise) in past 7

years? When did things change?

Prof Kay Wilhelm

GP and daughter both know her well and are concerned

5

Psychiatrist Perspective

What is the trajectory?

• Initially doing well but now depressed (illness factors, growing

isolation, realisation)

• Depressed all along (personality style, difficulty coping, being in

new role)

• Depressed all along now much worse

Prof Kay Wilhelm

Psychiatrist Perspective

Context for trajectory

Prof Kay Wilhelm

Age Life events Comments Medical Hx 0-5 Raised on farm, youngest of 4 Sibs at school, lonely 5-12 Local primary Shy, average student 12-16 Started local HS Appendix out 16 Finished school after SC Met Arthur in year 10 18 Married Arthur ‘Love of my life’ 20 First child ‘Busy years’ 22 2nd child 24 3rd child (followed miscarriage) Took 6 months to recover Post natal depression 26 4th child Given ADM by GP 30 Bought house on coast near parents Happy years, camping holidays, kids doing well, I was content Father died suddenly Cried for weeks, Mo also very sad. “We comforted each other” Arthur: ‘health scare’ Mother died 48 Arthur died Life lost its meaning Crying++++ Menopause 50 Best friend Dx breast Ca Onset of Rh arthritis Rx prednisone initially Worsening depression 55

Example of time line

6

Psychiatrist Perspective

Prof Kay Wilhelm

Psychiatrist Perspective

Clinical Depression

• Key features

– ↓Self-esteem

– Self-criticism – Depressed mood

• Nonspecific features

– Insomnia – Libido changes – Fatigue – Anxiety – Poor concentration – Appetite/weight changes

Prof Kay Wilhelm

• Concerning features

– Anhedonia – Amotivation – Nonreactive mood – Rumination – Hopeless/helplessness – Diurnal variation and – Early morning waking – Psychomotor retardation – Cognitive changes – Suicidality – Agitation – Psychosis Past history of bipolar disorder/ major depression +/-panic / vascular disease/hypertension diabetes/cancer

7

Psychiatrist Perspective

Structural Melancholia

• Older onset (eg. 60+ years)
• Family Hx of depression less significant
• Cerebrovascular disease more common
• Poorer response to antidepressants/ECT
• Risk of delirium
• Mechanism: Structural disruption of circuits linking basal ganglia

and pre-frontal circuits, presaging full dementia in months or years

Prof Kay Wilhelm

Cognitive processing problems: ↓ concentration, inattention, ‘pseudo-dementia’ picture Retardation and/or agitation Based on observation: Family members report CHANGE in behaviour

Psychiatrist Perspective

Suicide risk assessment

• Is she using alcohol/tobacco? analgesics? sedatives? stimulants?
• Does she have a depressive episode? panic? agitation?
• Any previous Hx of suicidality?
• When did ideas start in relationship to grief, depression?
• What does she have to live for?
• Has she plans? Has she acted on them?
• What access does she have?
• Who can she talk to?
• Is she concerned herself?

Prof Kay Wilhelm

8

Psychiatrist Perspective

Addressing different trajectories

Prof Kay Wilhelm

Social Worker Perspective

Mr Greg Roberts

Greg’s Face Value Assessment of Case

• Dorothy has a Chronic Adjustment Disorder?
• Loss of a primary reciprocal attachment figure (Arthur)
• Has lived life for 7 years without tangible connections to primary

reciprocal attachment figure and has not adjusted to this (some resilience evident to survive that long?)

• Adjustment may occur through development of symbolic

attachments to reciprocal attachment figure (Mikulincer & Shaver 2008) PLUS - strategies for self-soothing?

• Need to manage the changed relationship to the deceased (Klass,

Silverman & Nickman 1996)

9

Social Worker Perspective

Depression or Complicated Grief?

• Depression – generalised lowered mood that impairs daily

functioning in life

• Complicated Grief (Prolonged Grief Disorder) – intrusive/unabated

thoughts of deceased that impairs daily functioning of life and affects mood

• Adjustment Disorder – heightened stress reaction to change/loss

that brings changes in mood (depressed/anxious/combined) and affects daily functioning in life (can be acute or chronic)

Mr Greg Roberts

Social Worker Perspective

Principles for Integrated Approach

• Thorough assessment of Dorothy – K10, PHQ-9, WEMWBS, ICG

(inventory of complicated grief), DIAD (diagnostic inventory adjustment disorder)

• MHCP/referral to establish relationship between GP and Allied

Health Professionals

• Combined focus of ‘understanding’ (meaning/adjustment/reframing)

and ‘treatment’ (symptomatology/physiological change)

• Clarification and monitoring of statement “don’t want to be here” –

??an expression of inability to adjust to Arthur’s death (passive - giving up?) OR ??actively being suicidal (active – plan to die?)

Mr Greg Roberts

10

Social Worker Perspective

Challenges, Tips, Strategies for Dorothy

• Consistent communication pathways amongst interdisciplinary team

can be challenging

• Dorothy needs to be aware of different focus of each professional

and purpose of their interventions (invite Dorothy’s sense of self- agency)

• Combine a willingness to understand and work with the

‘functionality’ of grief (as part of adjustment to change/loss), along with treatment of symptoms that impair daily living

• Assist Dorothy in establishing meaningful connections/activities in

life, as it is now, rather than simply trying to return to past connections/activities, as they were then – life has changed and can never be the same as it was!

Mr Greg Roberts

Social Worker Perspective

Relevant Contemporary Theories for Dorothy’s Case

• Dual Process Model (DPM) (Stroebe & Schut)
• Two Track Model (Rubin)
• Continuing Bonds (Klass, Sliverman & Nickman)
• Expert Companioning (Wolfelt)
• Exquisite Witnessing (Jeffreys)

Mr Greg Roberts

11

Psychology Academic Perspective

The role of the General Practitioner

• Primary care and General Practitioners (GPs) have a clear role in

mental health generally and in bereavement support specifically

• The role of the GP in appropriate support and referral
• Relies heavily on:

– GPs’ knowledge – GPs’ communication and empathic listening – GPs’ willingness to refer

• A UK study found that had little awareness of contemporary

understandings of grief (Wiles et al., 2002)

• Education on dying, death and bereavement is often limited in

medical schools (Breen et al., 2012; Dickenson, 2007)

A/Prof Moira O’Connor

Psychology Academic Perspective

General Practitioners’ experiences

• In a study of GPs, we found (O’Connor & Breen, 2014):

– a lack of clarity – a lack of consistency – piece-meal knowledge

• Some GPs referred but others were very unwilling
• There were/are several barriers
• Focus on own ideas and experiences – could lead to problems for the

GP or other health professional

• Health professionals generally may emphasise their ‘worst’ type of

loss

• Complicated or prolonged grief reactions may be more related to

background factors such as relationship with the person who has died

• r attachment style (Lobb et al., 2010)

A/Prof Moira O’Connor

12

Psychology Academic Perspective

Public health model of bereavement

• The public health model of grief:

– emphasises that most people do not need any extra support other than family or friends – some people need community supports – and a significant minority need access to a mental health professional

(Aoun et al., 2012) A/Prof Moira O’Connor

Psychology Academic Perspective

Complications of grief

• Prolonged grief disorder (PGD) is a more complicated form of grief
• It causes significant social and occupational impairment
• It is associated with:

– suicidality – poorer health-related quality of life – substance abuse – and a reduced likelihood to seek assistance from mental health services

• It involves:

– separation distress – an unrelenting yearning for the deceased – a sense of meaninglessness, and difficulty accepting the loss

• All of which remain elevated for 6 months or more following the loss

A/Prof Moira O’Connor

13

Psychology Academic Perspective

What is needed?

• Grief education needs to alert health professionals (and the

community) to the range of responses

• We need to target care appropriately to those most in need, based on

the complexity and persistence of grief symptoms

• We also need interventions including one-on-one but also other

forms of interventions and supports

A/Prof Moira O’Connor

Psychology Academic Perspective

References

Aoun SM, Breen LJ, O’Connor M, Nordstrom C, Rumbold B: A public health approach to bereavement support services in palliative care. Aust N Z J Public Health 2012, 36:14–16. Breen L, Fernandez M, O’Connor M, Pember AJ: The preparation of graduate health professionals for working with bereaved clients: an Australian perspective. Omega 2012, 66:313–332. Dickinson GE: End-of-life and palliative care issues in medical and nursing schools in the United States. Death Stud 2007, 31:713–726. Lobb EA, Kristjanson LJ, Aoun SM, Monterosso L, Halkett GKB, Davies A: Predictors of complicated grief: a systematic review of empirical studies. Death Stud 2010, 34:673–698. O’Connor M, Breen LJ: General Practitioners’ experiences of bereavement care and their educational support needs: a qualitative study. BMC Medical Educ 2014, 14:59. Wiles R, Jarrett N, Payne S, Field D: Referrals for bereavement counselling in primary care: a qualitative study. Patient Educ Couns 2002, 48:79–85.

A/Prof Moira O’Connor

14 Q&A session

Thank you for your participation

• Please ensure you complete the exit survey before you log out (it will appear
• n your screen after the session closes). Certificates of attendance for this

webinar will be issued within two weeks.

• Each participant will be sent a link to online resources associated with this

webinar within one week.

• Upcoming webinars:

Working collaboratively to address the social and emotional well-being of older LGBTI people Wednesday, 27th April 2016 Working collaboratively to support students experiencing anxiety whilst completing end of high school studies Wednesday, 25th May 2016

15

Are you interested in leading a face-to-face network of mental health professionals in your local area? MHPN can support you to do so. Please fill out the relevant section in the exit survey. MHPN will follow up with you directly. For more information about MHPN networks and online activities, visit www.mhpn.org.au

Thank you for your contribution and participation